A new systematic review on the safety implications of missed test results in hospitalized patients has just come out (Callen 2011). This is an issue we have harped upon in many previous columns and the findings in the new review are no less frightening. They found lack of followup on test results ranged from 20-60% for inpatients and 1-75% for emergency room patients. And the lack of followup had clinical implications since some of the results were considered critical or urgent or otherwise actionable.
A second recent paper described lessons learned from implementation of a computerized application for tracking pending test results at discharge at Partners Healthcare in Boston (Dalal 2011). After implementation a survey was sent to multiple potential users of the system and results of use of the application were disappointing. Almost half the respondents never used the application and most of the others used it only 1-2 times per week. Barriers to use included not having enough time, being inundated with irrelevant results, not fitting into the workflow, and getting results on patients not belonging to them. Most, however, agreed that a well-designed computerized application could be valuable in helping manage test results at discharge. Being able to prioritize or filter which test results they want to see was important.
The issue of attribution of a patient to a physician is harder than it sounds. Tests may originally be ordered in the ER prior to the decision to admit. In such cases the ER physician’s name may be attached to such tests. The patient then gets admitted under one attending or hospitalist but those physicians may also change during the course of a hospitalization. Yet tests they ordered may be attributed to them. The situation gets even more complicated in academic medical centers where multiple housestaff are involved in care. Ultimately you want all test results to come back to the attending of record at the time of discharge so that he/she can identify pending tests results and note them in the discharge summary. It also needs to be made clear who will be responsible for following up on those pending test results. We always recommend that be discussed in a phone call at the transition of care but that is not always possible. But it is important. In our March 9, 2010 Patient Safety Tip of the Week “Were et al 2009) which showed that only 16% of tests with results pending actually are documented in discharge summaries. They identified multiple changes in attendings as an issue and difficulty identifying the physician who will ultimately follow the patient after discharge. We also noted in our October 13, 2009 Patient Safety Tip of the Week “Slipping Through the Cracks that studies have shown sending reports to two physicians, rather than increasing the likelihood someone will follow up, actually doubles the risk that no one will follow up (Singh 2009)!” we noted a study (
While technological solutions are likely to be of benefit, to date there is scant evidence that they have had a significant impact on this problem. The Callen paper notes that having an online endorsement or acknowledgement feature would at least help organizations better track how important test results are being communicated.
Suffice it to say that the ideal system for ensuring followup of all test results remains elusive.
See also our other columns on communicating significant results:
Callen J, Georgiou A, Li J, Westbrook JI. The safety implications of missed test results for hospitalised patients: a systematic review. BMJ Qual Saf 2011; 20: 194-199 Published Online First: 7 February 2011
Dalal AK, Poon EG, Karson AS, et al. Lessons learned from implementation of a computerized application for pending tests at hospital discharge. Journal of Hospital Medicine 2011; 6(1): 16-21 (first published online November 15, 2011)
Were MC, Li X, Kesterson J, et al. Adequacy of Hospital Discharge Summaries in Documenting Tests with Pending Results and Outpatient Follow-up Providers. Journal of General Internal Medicine 2009; 24(9): 1002-1006
Singh H, Thomas EJ, Mani S, et al. Timely Follow-up of Abnormal Diagnostic Imaging Test Results in an Outpatient Setting. Arch Intern Med. 2009; 169(17): 1578-1586.